Provider Demographics
NPI:1467964635
Name:WALLIS, JOHN MATHER (PHARMD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:MATHER
Last Name:WALLIS
Suffix:
Gender:M
Credentials:PHARMD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:247 WOODHAVEN DR UNIT 6J
Mailing Address - Street 2:
Mailing Address - City:WHITE RIVER JUNCTION
Mailing Address - State:VT
Mailing Address - Zip Code:05001-2831
Mailing Address - Country:US
Mailing Address - Phone:603-252-5981
Mailing Address - Fax:
Practice Address - Street 1:123 NASHUA RD
Practice Address - Street 2:
Practice Address - City:LONDONDERRY
Practice Address - State:NH
Practice Address - Zip Code:03053-3453
Practice Address - Country:US
Practice Address - Phone:603-437-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-10-28
Last Update Date:2017-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NHPHCY-04332183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist